SPECIALTY OF VASCULAR SURGERY Delineatin f Clinical Privileges Criteria fr granting privileges: Current certificatin by the American Bard f Surgery, r the American Ostepathic Bard f Surgery, and subspecialty certificatin in Vascular Surgery. Current certificatin by the American Bard f Thracic Surgery, r the American Ostepathic Bard f Thracic Cardivascular Surgery. Successful cmpletin f an ACGME, r AOA accredited pst-graduate General Surgery and pstgraduate Vascular Surgery and bard certificatin within 5 years f prgram cmpletin. Successful cmpletin f an ACGME r AOA accredited pst-graduate training prgrams in Thracic Surgery and bard certificatin within 5 years f prgram cmpletin. Applicants will be requested t prvide dcumentatin f practice and current clinical cmpetence as defined n the attached cmpetency grid. Applicants have the burden f prducing infrmatin deemed adequate by the hspital fr a prper evaluatin f current clinical cmpetence, and ther qualificatins and fr reslving any dubts. Current Clinical Cmpetence - MLH In additin t the required educatin, experience and/r training specified n each DOP (Delineatin f Privilege) frm, dcumentatin f current clinical cmpetence is required. TJC (The Jint Cmmissin) describes current clinical cmpetence as having perfrmed the privilege recently and perfrmed it well. Current clinical cmpetence is assessed prir t granting privileges initially and is reassessed when renewing privileges at reappintment fr maintenance f privileges. Current Clinical Cmpetence (CCC) may be lcatin specific (acute hspital care/surgery center (ASC) and/r age specific (adult, pediatric,nenatal). This shuld nt be cnfused with FPPE (Fcused Prfessinal Practice Evaluatin) FPPE: an evaluatin f clinical cmpetence f all new privileges as perfrmed at the specific licensed MLH facility (MHMH, MHOBH, Fayette, MECH) fr which they have been initially granted. This applies t privileges fr all new applicants as well as t new/additinal privileges fr current members. Bth FPPE and current clinical cmpetence assessments are privilege-specific. FPPE is cnducted during the perid after granting new/additinal privileges. FPPE must ccur at the MLH facility(ies) where privileges/membership are held. Current clinical cmpetence may be evaluated frm case lgs prvided by nn-mlh facilities. Current Clinical Cmpetence: Requirements fr New Applicants If applying directly frm training, r based n the training received in a frmal training prgram, prvider shuld submit case* lgs frm the prgram authenticated by the prgram directr alng with their recmmendatin attesting t the cmparable training, experience and qualificatins relative t the criteria fr the clinical privileges requested. Bard apprved: March 2011 1
If applying mre than 1 year after training cmpletin, submit the fllwing: Aggregate data frm acute care r surgery center facility fr the previus 12 mnth time perid, identifying the tp 10 diagnsis cdes and the number f patients per cde. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. Prcedure list frm acute care r surgery center facility fr the previus 12 mnth time perid, identifying the tp 10 CPT/ICD cdes and the number f prcedures per cde. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. Case lgs (see specificatins belw) fr any special privileges requested that meet the criteria specific fr the number f prcedures defined fr current clinical cmpetence. Current Clinical Cmpetence: Maintenance f Privileges fr Current Members Fr active staff members: MLH surce data will be aggregated t review cases and prcedures perfrmed. and/r special privileges, the practitiner will be required t submit additinal case lgs frm ther facilities. If this des nt meet the minimum requirement fr cre Fr curtesy staff members with lw activity and fr certain active staff with activity that has diminished and is nw lw: Department chair recmmendatin shuld be btained frm their primary facility; and the practitiner shuld submit the fllwing: Aggregate data frm acute care r surgery center facility fr the previus 12 mnth time perid, identifying the tp 10 diagnsis cdes and the number f patients per cde. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. Prcedure list frm acute care r surgery center facility fr the previus 12 mnth time perid, identifying the tp 10 CPT/ICD cdes and the number f prcedures per cde. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. Case lgs (see specificatins belw) fr any special privileges requested that meet the specific number f prcedures defined fr current clinical cmpetence. Case Lgs All required case lgs and/r prcedure lists must cntain the fllwing infrmatin at a minimum: Date, patient identifier, CPT/ICD prcedure cde, diagnsis, cmplicatins, and dispsitin, and the facility name, name/title f the persn authenticating the lg, signature, date signed, and cntact infrmatin. If the infrmatin requested is nt available, please prvide an explanatin. *A case is defined as an episde f care either cgnitive r prcedural. Fr interpretive care, case is interpretatin f ne diagnstic study. OPPE (Onging Prfessinal Perfrmance Evaluatin) The Jint Cmmissin (TJC) requires OPPE peridically (mre frequently than annually) in the facility where membership/privileges are held. T assure OPPE requirements are satisfied, the practitiner must peridically exercise the privileges in the MLH facility(ies) where he/she has membership. OPPE must ccur regularly n patient encunters in the MLH facility(ies) where privileges/membership are held. Bard apprved: March 2011 2
Specialty/Prcedure Delineatin f Privilege Frm Educatin/Training Dcumentatin fr Initial Granting Initial Applicatin (Prf f current clinical cmpetence) FPPE Validatin f cmpetence after appintment and/r granting f a new r additinal privilege (T be cmpleted within ne year) Maintenance Requirements Vascular Surgery Cre Vascular Surgery Pediatric Cre Current certificatin by the American Bard f Surgery, r the American Ostepathic Bard f Surgery and subspecialty certificatin in Vascular Surgery Current certificatin by the American Bard f Thracic Surgery, r the American Ostepathic Bard f Thracic Cardivascular Surgery Successful cmpletin f an ACGME r AOA accredited pstgraduate general surgery and pstgraduate vascular surgery and bard certificatin within 5 years f cmpletin. Successful cmpletin f an ACGME r AOA accredited pstgraduate thracic surgery and bard certificatin within 5 years f cmpletin. Current certificatin by the American Bard f Surgery, r the American Ostepathic Bard f Surgery and subspecialty certificatin in Vascular Surgery Current certificatin by the American Bard f Thracic Surgery, r the American Ostepathic Bard f Thracic Cardivascular Surgery Successful cmpletin f an ACGME r AOA accredited pstgraduate general surgery and pstgraduate vascular surgery and bard Aggregate data frm primary practice facility fr the previus 12 mnth time perid indentifying the tp 10 diagnsis cdes and the number f inpatients per cde. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. Prcedure list frm primary practice facility fr the previus 12 mnth time perid identifying the tp 10 CPT/ICD cdes and the number f prcedures per cde. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. Aggregate data frm primary practice facility fr the previus 12 mnth time perid indentifying the tp 10 diagnsis cdes and the number f inpatients per cde. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. Prcedure list frm primary practice facility fr the previus 12 mnth time perid identifying the tp 10 CPT/ICD cdes and the number f prcedures per cde. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an First 5 majr cases First 5 majr cases MLH Data will be btained fr active members when available, the applicant shuld supply additinal case lgs frm ther facilities HIM departments, if necessary, t meet the minimum requirement(s) t be cnsidered fr the privilege. Curtesy members shuld supply case lgs frm ther facilities HIM departments t meet the minimum requirement(s) t be cnsidered fr the privilege. Aggregate data submitted shuld include the tp 10 diagnsis cdes, with the number f inpatients per cde, and prcedure lists indicating the tp 10 CPT/ICD cdes, with the number f prcedures per cde fr the previus 12 mnths. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. Department chair recmmendatin will be btained frm primary practice facility. MLH Data will be btained fr active members when available, the applicant shuld supply additinal case lgs frm ther facilities HIM departments, if necessary, t meet the minimum requirement(s) t be cnsidered fr the privilege. Curtesy members shuld supply case lgs frm ther facilities HIM departments t meet the minimum requirement(s) t be cnsidered fr the privilege. Aggregate data submitted shuld include the tp 10 diagnsis cdes, with the number f inpatients per cde, and prcedure lists indicating the tp 10 CPT/ICD cdes, with the number f prcedures per cde fr the previus 12 mnths. Any cmplicatins/pr utcmes shuld be Bard apprved: March 2011 3
Specialty/Prcedure Delineatin f Privilege Frm Educatin/Training Dcumentatin fr Initial Granting Initial Applicatin (Prf f current clinical cmpetence) FPPE Validatin f cmpetence after appintment and/r granting f a new r additinal privilege (T be cmpleted within ne year) Maintenance Requirements Use f Laser certificatin within 5 years f cmpletin. Successful cmpletin f an ACGME r AOA accredited pstgraduate thracic surgery and bard certificatin within 5 years f cmpletin. Cmpletin f an apprved eight hur minimum CME curse which includes training in laser principles and safety, basic laser physics, laser tissue interactin, discussins f the clinical specialty field and hands-n experience with lasers. A letter utlining the cntent and successful cmpletin f curse must be submitted, r dcumentatin f successful cmpletin f an apprved residency in a specialty r subspecialty which included training in laser principles and safety, basic laser physics, laser tissue interactin, discussins f the clinical specialty field and a minimum f six hurs bservatin and hands-n experience with lasers. explanatin. First 5 cases delineated and accmpanied by an explanatin. Department chair recmmendatin will be btained frm primary practice facility. Case lg dcumenting 5 prcedures within the previus 24 mnths Bard apprved: March 2011 4
Vascular Surgery Cre Privilege: Admit, evaluate, diagnse, prvide cnsultatin and treatment t patients ages 13 r lder with diseases/disrders f the arterial, venus, and lymphatic circulatry systems, excluding vessels f the heart and excluding therapeutic interventins f the intracranial arteries. Physicians may prvide care t patients in the intensive care setting in cnfrmance with unit plicies. They may als assess, stabilize, and determine the dispsitin f patients with emergency cnditins cnsistent with medical staff plicy regarding emergency and cnsultative call services. The cre privileges in this specialty include the prcedures n the attached list and such ther prcedures that are extensins f the same techniques and skills. Operative prcedures: Amputatins f the upper r lwer extremity Central venus access catheters and prts Hemdialysis access prcedures Diagnstic bipsy r ther diagnstic prcedures n bld vessels Repair f aneurysms f the thracic arta, thracabdminal arta, abdminal arta, iliac artery, visceral/renal arteries, artic arch branch vessels, cartid and vertebral arteries, and peripheral arteries Recnstructin and repair f the nn-cardiac and nn-intracranial arteries and veins f the bdy including the thracic arta, thracabdminal arta, abdminal arta, iliac artery, visceral/renal arteries, artic arch branch vessels, cartid and vertebral arteries, peripheral arteries, central veins, and peripheral veins (e.g., endarterectmy, thrmbectmy, emblectmy, bypass grafting, prsthetic graft, autlgus vein, in situ vein, and extra-anatmic bypass) Decmpressive fascitmies f the upper and lwer extremities Tempral artery bipsy Vein ligatin and stripping Operatins fr thracic utlet decmpressin Vascular expsure fr peratins f the cervical, thracic, and lumbar spine Cervical, thracic, and lumbar sympathectmy Endvascular prcedures: Diagnstic arterigraphy (excluding intracardiac) including pulmnary arterigraphy Diagnstic vengraphy (excluding intracardiac) Repair (e.g., stent, stent graft, and emblizatin) f aneurysms f the thracic arta, thracabdminal arta, abdminal arta, iliac artery, visceral/renal arteries, artic arch branch vessels, the cartid and vertebral arteries, and peripheral arteries Recnstructin and repair (e.g., angiplasty, stent, stent graft, and emblizatin) f the nn-cardiac and nnintracranial arteries and veins f the bdy including the thracic arta, thracabdminal arta, abdminal arta, iliac artery, visceral/renal arteries, artic arch branch vessels, the cartid and vertebral arteries, and peripheral arteries. Open and percutaneus endvascular prcedures Placement f inferir vena cava filter Endvenus ablative therapy (laser r radifrequency) Bard apprved: March 2011 5
Intravascular ultrasngraphy Balln angiplasty Stent placement Stent graft placement Intra-arterial and intravenus thrmblytic therapy Emblizatin/ablatin, including transarterial chememblizatin Use f AngiVac and ther thrmbus aspiratin devices Vascular Diagnstic Labratry: Perfrmance and Interpretatin f arterial studies f the extremities Perfrmance and Interpretatin f venus studies f the extremities Perfrmance and Interpretatin f cerebrvascular studies Perfrmance and Interpretatin f visceral and abdminal arterial and venus studies Perfrmance and Interpretatin f transcranial studies Vascular Surgery Pediatric Cre Privilege: Admit, evaluate, diagnse, prvide cnsultatin and treatment t patients ages 12 r yunger with diseases/disrders f the arterial, venus, and lymphatic circulatry systems, excluding vessels f the heart and excluding therapeutic interventins f the intracranial arteries. Physicians may prvide care t patients in the intensive care setting in cnfrmance with unit plicies. They may als assess, stabilize, and determine the dispsitin f patients with emergency cnditins cnsistent with medical staff plicy regarding emergency and cnsultative call services. The cre privileges in this specialty include the prcedures n the attached list and such ther prcedures that are extensins f the same techniques and skills. Operative prcedures: Amputatins f the upper r lwer extremity Central venus access catheters and prts Hemdialysis access prcedures Diagnstic bipsy r ther diagnstic prcedures n bld vessels Repair f aneurysms f the thracic arta, thracabdminal arta, abdminal arta, iliac artery, visceral/renal arteries, artic arch branch vessels, cartid and vertebral arteries, and peripheral arteries Recnstructin and repair f the nn-cardiac and nn-intracranial arteries and veins f the bdy including the thracic arta, thracabdminal arta, abdminal arta, iliac artery, visceral/renal arteries, artic arch branch vessels, cartid and vertebral arteries, peripheral arteries, central veins, and peripheral veins (e.g., endarterectmy, thrmbectmy, emblectmy, bypass grafting, prsthetic graft, autlgus vein, in situ vein, and extra-anatmic bypass) Decmpressive fascitmies f the upper and lwer extremities Tempral artery bipsy Vein ligatin and stripping Operatins fr thracic utlet decmpressin Bard apprved: March 2011 6
Vascular expsure fr peratins f the cervical, thracic, and lumbar spine Cervical, thracic, and lumbar sympathectmy Endvascular prcedures: Diagnstic arterigraphy (excluding intracardiac) including pulmnary arterigraphy Diagnstic vengraphy (excluding intracardiac) Repair (e.g., stent, stent graft, and emblizatin) f aneurysms f the thracic arta, thracabdminal arta, abdminal arta, iliac artery, visceral/renal arteries, artic arch branch vessels, the cartid and vertebral arteries, and peripheral arteries Recnstructin and repair (e.g., angiplasty, stent, stent graft, and emblizatin) f the nn-cardiac and nnintracranial arteries and veins f the bdy including the thracic arta, thracabdminal arta, abdminal arta, iliac artery, visceral/renal arteries, artic arch branch vessels, the cartid and vertebral arteries, and peripheral arteries. Open and percutaneus endvascular prcedures Placement f inferir vena cava filter Endvenus ablative therapy (laser r radifrequency) Intravascular ultrasngraphy Balln angiplasty Stent placement Stent graft placement Intra-arterial and intravenus thrmblytic therapy Emblizatin/ablatin, including transarterial chememblizatin Use f AngiVac and ther thrmbus aspiratin devices Vascular Diagnstic Labratry Perfrmance and Interpretatin f arterial studies f the extremities Perfrmance and Interpretatin f venus studies f the extremities Perfrmance and Interpretatin f cerebrvascular studies Perfrmance and Interpretatin f visceral and abdminal arterial and venus studies Perfrmance and Interpretatin f transcranial studies Special: The physician requesting special privileges must meet the minimum criteria fr the specialty cre and demnstrate the apprpriate pst graduate training and/r demnstrate successful cmpletin f an apprved, recgnized curse when such exists, r ther acceptable experience. Administratin f mderate sedatin: See Credentialing Plicy fr Sedatin and Analgesia by Nn-Anesthesilgists. Requires: Separate DOP, ACLS, NRP r PALS certificatin Cartid Stents: Requires: Separate DOP Rbtic Surgery: See Physician Credentialing requirements fr Rbtic Surgery. Requires: Separate DOP Bard apprved: March 2011 7
Vascular Surgery Clinical Privileges Check belw the particular privileges desired in Vascular Surgery fr each facility: Privilege Descriptin Age Limitatins Vascular Surgery Cre Please check () applicable age categries fr each privilege requested. Methdist Healthcare Memphis Hspitals (MHMH) Germantwn, Le Bnheur Medical Center, Nrth, Suth & University, Outpatient Clinics & Diagnstic Facilities Infants Children & (29 days Adlescents 2 Years) (2-18 years) Nenates (0-28 days) Adults & Adlescents (13-& Abve) Vascular Surgery Pediatric Cre Special Privileges Use f Laser Limitatins Clinical privileges are granted nly t the extent privileges are available at each facility. Darkly shaded areas represent privileges nt available t any practitiner due t the privilege nt being ffered by the facility. Nte: Privileges fr administratin f mderate sedatin, cartid stent placement and rbtic surgery require cmpletin f a separate Delineatin f Privilege frm. Acknwledgement f practitiner I have requested nly thse privileges fr which by educatin, training, current experience and demnstrated perfrmance I am qualified t perfrm and fr which I wish t exercise at the facilities indicated abve, t the extent services are available at each facility, and I understand that: (a) in exercising any clinical privileges granted, I am cnstrained by facility and medical staff plicies and rules applicable generally and any applicable t the particular situatin (b) any restrictin n the clinical privileges granted t me is waived in an emergency situatin and in such situatin my actins are gverned by the applicable sectin f the medical staff bylaws r related dcuments Physician's Signature Date Printed Name Bard apprved: March 2011 8